Author: Michael Chung, MD
Co Author #1: Dr. Ryan Smith
Co Author #2: Dr. Majid Ashfaq
Senior Editor: Rahul Kapur, MD
Editor: Haruki Ishii, MD

Patient Presentation:
A 59-year-old man with noncontributory past medical history presented with 1 year history of atraumatic medial left ankle pain.

History:
The pain was primarily located posterior to the medial malleolus, but radiated to the navicular bone, and was aggravated by ankle range of motion and walking.

The patient was previously evaluated by Podiatry and underwent a left ankle MRI that showed a possible small medial talar osteochondral defect and tenosynovitis of the posterior tibialis, flexor digitorum longus, and flexor hallucis longus tendons. He had a minimal relief with left ankle intraarticular and tarsal tunnel blocks, performed by Podiatry. Podiatry thought his pain was primarily due to loculated flexor hallucis longus tendon tenosynovitis causing tarsal tunnel compression and considered a tenosynovectomy and tarsal tunnel release.

During our initial assessment, however, the patient did not complain of paresthesias of the ankle/foot. Additionally, prior electrodiagnostic studies were negative.

Physical Exam:
On inspection of the left ankle, there was no atrophy, asymmetry, erythema, effusion, or gross deformities. He had tenderness to palpation over posterior to the medial malleolus, posterior tibialis tendon, and navicular bone. He did not have tenderness over Achilles tendon, lateral malleolus, anterior talo-fibular ligament, calcaneofibular ligament, or deltoid ligament. The patient demonstrated full range of motion with pain at end range of inversion. He demonstrated full strength in L1-S1 myotomes. He did not have pain with resisted ankle motion of the flexor hallucis longus, flexor digitorum longus, or ankle eversion. He had reproduction of medial ankle pain with resisted inversion and passive eversion. He had normal sensation of bilateral lower extremities. He had a negative Anterior Drawer, Talar Tilt, Posterior Drawer, syndesmotic squeeze, and tibial tunnel compression tests.

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